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e Division of Community Internal Medicine, Mayo Clinic, Rochester, Minnesota
Managing a multiplicity of illnesses, medications, and well-meaning family members is where geriatricians do their best work. This is where the burden of illness can overwhelm primary care providers who are not comfortable balancing the functional, physical, psychological, social, economic, and spiritual needs of the patient. This is where experience and judgment help in setting priorities and in making fundamental decisions on a plan of care.
How hard can 80-year-old kidneys be pushed to treat heart failure? How much is the heart failure contributing to the shortness of breath in the face of pulmonary fibrosis or 100 pack-years of smoking? Is the patient's poor sleep a result of heart disease, a bladder outlet obstruction, depression, boredom, or sore joints? Would any sleeping remedy help or just make matters worse, especially with regard to cognition? Most often, a combination of many of the above define the problem and perplex organ-specific physicians who like to place the patient either in or out of their acute model of care.
Although geriatrics might have a hard time deciding what it wants to be when it grows up, I am beyond midcareer and comfortable with life's decisions. The specialty of geriatrics is what I do and I mark every day in its company. The routine defines the practice and is not dissimilar to what many geriatricians do in an academic environment with more than modest clinical responsibilities. If we are to write the future history of geriatrics, perhaps we should be reminded that "history, although sometimes made up of the few acts of the great, is more often shaped by the many acts of the small" (1).
The practice is somewhat different from what many of my fellow internists are doing right down the corridor. Although we may see the same number of patients in a half-day, they know when I'm in town. The wheelchair traffic around my office space is the first hallmark. Next, we can do a head count of all the people moving in and out of each of my three exam rooms. I do not find burdensome the additional history provided by family, volunteers, home health aids, and the occasional case manager that shows up. Nurses also tell me my patients are the slowest when it comes to getting undressed. The dress–undress rate is rather fixed and can eat up much of our allocated time (either 20 or 40 minutes).
My patients are, on average, 7 years older than the rest of our internal medicine practice. We calculate panel size to determine patient volumes, and age does make some difference using ambulatory care group adjustment for case mix (2). Unfortunately, I have not been able to convince any of my colleagues that we should be counting all heads and not just patient heads when determining panel size.
Cognitive impairment in the outpatient setting is one of the great frailties of aging. In the nursing home, fully two thirds of my patients have dementia (3). Given the decade-long march of most dementias, particularly Alzheimer's disease, this is chronic disease care at its fullest. Another useful measure of disease burden and a reflection of chronic illness is the Charlson index (4). This too plays to Kane's definition of geriatrics and chronic disease care (5).
When life's journey nears its end, I am usually reminded not to stand in the way. Keeping someone pain free is often my last contact with patient and family. This practice is now central to clinical care for the aged, in harmony with Kane's concept of chronic disease care, and not just an end-of-life exercise. The stories I have heard these past 25 years are more a celebration of life than a surrender to our mortality.
Caught up in the day-to-day routine of seeing patients, "who can control his fate" (6)? We are defined by what we do, and at the same time we define the field. Chronic disease care with a premium on care is a juggling act for both the patient and the practitioner. It can be quite a performance. It includes a display of compassion, an understanding of the science of the day, and an honest recognition of the uncertainties about us. To care for the frail, we must understand the balance between autonomy and risk and appreciate the transitions from wellness to infirmity.
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This article has been cited by other articles:
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  J. E. Morley, J. H. Flaherty, and D. R. Thomas Editorial: Geriatricians, Continuous Quality Improvement, and Improved Care for Older Persons J. Gerontol. A Biol. Sci. Med. Sci., September 1, 2003; 58(9): M809 - 812. [Full Text] [PDF]
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J. E. Morley Editorial: Hot Topics in Geriatrics J. Gerontol. A Biol. Sci. Med. Sci., January 1, 2003; 58(1): M30 - 36. [Full Text] [PDF]
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D. R. Thomas Letters to the Editor: The Future History of Geriatrics: Consulting the Experts J. Gerontol. A Biol. Sci. Med. Sci., January 1, 2003; 58(1): M92 - 92. [Full Text] [PDF]
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